The effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis: Results from the global SECURE-AD registry

BACKGROUND

Limited data are available on the effects of systemic immunomodulatory treatments on COVID-19 outcomes in patients with atopic dermatitis (AD).

OBJECTIVE

To investigate COVID-19 outcomes in patients with AD treated with or without systemic immunomodulatory treatments, using a global registry platform.

METHODS

Clinicians were encouraged to report cases of COVID-19 in their patients with AD in the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Atopic Dermatitis (SECURE-AD) registry. Data entered from 1 April 2020 to 31 October 2021 were analysed using multivariable logistic regression. The primary outcome was hospitalization from COVID-19, according to AD treatment groups.

RESULTS

442 AD patients (mean age 35.9 years, 51.8% male) from 27 countries with strongly suspected or confirmed COVID-19 were included in analyses. 428 (96.8%) patients were treated with a single systemic therapy (n = 297 [67.2%]) or topical therapy only (n = 131 [29.6%]). Most patients treated with systemic therapies received dupilumab (n = 216). Fourteen patients (3.2%) received a combination of systemic therapies. Twenty-six patients (5.9%) were hospitalized. No deaths were reported. Patients treated with topical treatments had significantly higher odds of hospitalization, compared with those treated with dupilumab monotherapy (odds ratio (OR) 4.65 [95%CI 1.71-14.78]), including after adjustment for confounding variables (adjusted OR (aOR) 4.99 [95%CI 1.4-20.84]). Combination systemic therapy which did not include systemic corticosteroids was associated with increased odds of hospitalization, compared with single agent non-steroidal immunosuppressive systemic treatment (OR 8.09 [95%CI 0.4-59.96], aOR 37.57 [95%CI 1.05-871.11]). Hospitalization was most likely in patients treated with combination systemic therapy which included systemic corticosteroids (OR 40.43 [95%CI 8.16-207.49], aOR 45.75 [95%CI 4.54-616.22]).

CONCLUSIONS

Overall, the risk of COVID-19 complications appears low in patients with AD, even when treated with systemic immunomodulatory agents. Dupilumab monotherapy was associated with lower hospitalization than other therapies. Combination systemic treatment, particularly combinations including systemic corticosteroids, was associated with the highest risk of severe COVID-19.

Relationship Between Physician Burnout and Patient's Perception of Bedside Time Spent by Physicians

Although the adverse effect of burnout on physicians has been widely documented, studies have shown an inconsistent relationship between burnout and the quality of patient care. We hypothesized that physician burnout will have an inverse relationship with the time spent at the bedside by physicians. In a cross-sectional study, we surveyed patients on their perception of the time spent by their physician on the day of the survey (4 categories: 0-5, 6-10, 11-15, >15 minutes). Oldenburg Burnout Inventory was used to assess physician burnout; burnout was defined as high levels of both exhaustion (≥2.25) and disengagement (≥2.10). Among the 1374 patients, the most commonly reported time spent at bedside category was 6-10 minutes (n=614, 45%). Among the 95 physicians who saw these patients, burnout was present in 44 (46%), with a higher prevalence in women (61% vs 39%; P=0.04). Using ordered logistic regression, we found no relationship between physician burnout and patient's perception of bedside time spent, without adjustment (odds ratio: 0.86, 95% CI: 0.65-1.16) or with adjustment (odds ratio: 0.85, 95% CI: 0.64-1.12) for potential confounders. Although physician burnout is not associated with patient perception of time spent at bedside, it may be associated with other patient outcomes that require further research.

Seasonal variation in photosynthetic rates and satellite-based GPP estimation over mangrove forest

In view of increasing anthropogenic influences and global changes, quantification of carbon assimilation through photosynthesis has gained tremendous significance. Precise estimation of Gross Primary Productivity (GPP) is essential for several ecosystem models and is typically done using coarser scale satellite data. The mangrove ecosystem, which offers significant protection to the coastal environment, is one of the critical habitats from a global change point of view. Light use efficiency (LUE) was measured using diurnal in situ photosynthetic rate observations for 13 dominant mangrove species for 3 seasons at each of the three mangrove dominant test-sites situated along the east and west coast of India. Variations in photosynthetic rates among these species were studied for 3 seasons that indicated varying responses of mangrove ecosystem at each site. Among all species, Rhizophora mucronata and Sonneratia apetala indicated higher values at two of the test-sites. IRS Resourcesat-2 LISS-IV datasets were used for the estimation of GPP. Mean GPP for all the sites varied from 1.2 to 7.7 g C m^-2 day^-1 with maximum value of 14.4 g C m^-2 day^-1. Mean values of GPP varied across the sites, based on its maximum LUE values and available photosynthetically active radiation (PAR). The results provide GPP values at much better spatial resolution for a threatened habitat like mangroves that typically survive in a narrow habitat along the coasts.

Overview of an emergent, arts-based resiliency curriculum to mitigate medical trainee burnout

Background: Physician and trainee burnout are becoming an epidemic within the medical community.  Objective: This paper describes an innovative emergent curriculum that uses narrative medicine, creative activities, and group discussions to alleviate burnout.  Methods: Between August 2016 and August 2019, 394 medical trainees participated in sessions that focused on themes relevant to promoting wellbeing, such as maintaining sensitivity to patients and finding balance. After the activities, trainees answered survey questions that related to the session theme and aided in reflection.  Discussion: The student responses showed the program supported introspection that left students feeling less tired, more relaxed, and connected with one another.

Spirituality and satisfaction with physicians among hospitalized patients

We examined the relationship between a patient's spirituality and satisfaction with physicians during hospitalization. Data were collected using the Daily Spiritual Experience Scale (DSES), the Tool to Assess Inpatient Satisfaction with Care from Hospitalists (TAISCH) and a five-question, internally-developed, patient satisfaction questionnaire (5QS). Scores were rescaled from 0 to 100 for easy comparison. Results showed a statistically significant increase in patient satisfaction with increasing spirituality. In the unadjusted model, each 1% increase in DSES score (or 1% decrease in spirituality) was associated with 0.21% (p < 0.001) and 0.14% (p = 0.002) decrease in patient satisfaction with physicians as measured by 5QS and TAISCH respectively. The results were consistent after adjustment for the patient's age, gender, and race. With the increasing influence, patient satisfaction scores have on the health care system, the results from this study help us better understand how these scores are influenced.

Formulation and development of floating multiple-unit minitablets of Nimodipine without using a gas-generating agent: in vitro and in vivo characterization

Background

Floating drug delivery systems have been reported for different active pharmaceutical ingredients as single-unit tablets with gas-generating agents. In this present research, the formulation of floating multiple-unit minitablets of Nimodipine without using gas-generating agent was attempted with an objective of increased residence time, sustain-release and improved oral bioavailability. Solid dispersion with different ratios (1:0.5, 1:1, 1:1.5, 1:2, 1:2.5) of drug with the lipophilic carrier such as Compritol ATO 888, Gelucire 43/01, G39/01 and Precirol ATO 05 was formulated using melt granulation technique. The adsorbent Sylysia 350 to lipophilic carrier is maintained at 1:1. The granules were compressed into minitablets weighing 15 mg and were filled into a ‘0’ size capsule.

Results

Differential scanning calorimetry study justified no interaction of the drug with excipients. The formulations which exhibited desirable flow property, floating lag time less than 1 min and floating time of 12 h were further characterized for various post-compression parameters. The optimized single-dose (capsule) of floating multiple-unit minitablets of Nimodipine consisting of 60 mg of drug, 120 mg of G43/01 and 120 mg of Sylysia 350 showed an average of floating lag time within 24.48 s, floating time of 14.32 h and sustained-release up to 12 h. Pharmacokinetic study of the optimized formulation (F9) showed nearly 2.5 times increase in area under the curve with increased residence time in comparison to aqueous suspension of Nimodipine. The stability study revealed no significant change in various parameters before and after storage.

Conclusion

Hence, gelucire 43/01-based multiple-unit minitablets of Nimodipine can be considered a promising approach for sustaining the drug release with gastric retention for 12 h without using gas-generating agent.

An Investigation on the Coinfection of Measles and HSV-1 in Hospitalized Acute Encephalitis Syndrome Patients in Eastern India

Acute encephalitis syndrome (AES) is a clinical condition that occurs due to infectious and noninfectious agents- however, viruses are considered to be the dominant pathogen. agents- however, viruses are considered to be the dominant pathogen. In this study, suspected AES cases were enrolled and tested for viral etiology through serology and polymerase chain reaction (PCR)/reverse transcriptase PCR from August 2012-July 2013. During this period, 820 cases were investigated and 96 cases were diagnosed to have a viral etiology whereas 20 patients had IgM antibodies for measles in serum and HSV-1 DNA in cerebrospinal fluid. All 20 of the patients were children below 14 years of age. The median hospital stay was 15 days (IQR: 14.2-17 days) and median GCS score was 7(IQR: 6-8) and were significantly different with patients with co-infections when comapred with patients having HSV-1 infection only. It may be suspected that the measles infection may have a role in the pathogenesis and thus an impact on the prognosis of the AES when present with HSV-1.

Molecular and phylogenetic analysis of the dengue strains circulating in Odisha, India

Dengue has emerged as a major public health challenge in terms of both changing clinical pattern and epidemiological features. The state of Odisha reported first dengue epidemic in the year 2010 and this continued each year in epidemic form during post monsoon period gradually becoming an endemic phenomenon. Present study depicts the changing epidemiological and clinical pattern of dengue with reference to its serotypes and genotypes. The study included 5320 suspected dengue cases from different health facilities of the state during 2010-2017. Dengue NS1 antigen and IgM antibody was done through ELISA. Serotyping was done through RTPCR by amplifying a part of core-pre-membrane gene (CprM) followed by sequencing and phylogenetic analysis. Dengue IgM antibody in 17.7% cases and NS1 antigen in 53.20% cases was detected. Dengue serotype 2 (DEN-2) was the only serotype detected in 2010 and 2011 where as all four serotypes 1, 2, 3, 4 were detected in 2012-2017, DEN-2 being dominant but in 2017 DEN-3 was found to be dominant. Phylogenetic analysis revealed genotype IV of DEN-2 and genotype III of DEN-1 and DEN-3 circulating in this region. In 6 cases involvement of DEN-2 in clinically evident encephalitis cases is an important observation in this region and needs public health attention. High prevalence of dengue was observed without any previous reported outbreaks in the state with increased number of cases from 2010 to 2012 affecting both urban and rural areas. High incidence in 2012 was due to co-circulation of more than one serotype which continued in the following years. Severity in some cases was associated with mixed infection but in most cases it was mild indicating the endemic nature of the virus in most parts of Odisha.

Relationship of Physicians' Rapport with Patients' Satisfaction and Psychological Well-being During Hospitalization

Objective The purpose of this study was to assess the association between the psychological well-being and satisfaction of patients with physicians during their hospitalization. Methods This cross-sectional study was conducted at a local hospital using the following surveys: Brief Inventory of Thriving (BIT), tool to assess inpatient satisfaction with care from hospitalists (TAISCH) survey, and Erlanger Internal Patient satisfaction survey addressing demographic questions and questions on physicians' quality of care and etiquette. Mixed linear regression models were created to examine the effect of psychological well-being on patient satisfaction. Models were adjusted for age, race, and gender, and all analyses were performed in R 3.1.1 using the 'lme4' package with statistical significance set at p<0.05. Results A total of 360 patients were enrolled in this analysis and the mean age of the cohort was 54.5 years. In the unadjusted analysis, each unit increase in BIT score was associated with a 0.3% (95% CI:0.19-0.4, p<0.001) increase in mean satisfaction score using the five-domain questionnaire and a 0.25% (95%CI:0.16-0.34, p<0.01) increase in mean satisfaction score using the TAISCH questionnaire. Multivariable models, after adjusting confounding variables, also showed the direct and statistically significant relationship between patients' level of psychological well-being and patient satisfaction. Each unit increase in BIT score was associated with a 0.31% (95% CI:0.20-0.43, p<0.001) and 0.26% (95% CI:0.17-0.36, p<0.001) increase in mean satisfaction scores across the five-domain questionnaire and TAISCH questionnaire. Conclusions There is a positive correlation between the level of patients' psychological well-being and satisfaction with his/her physician with a statistical significance. With patient-specific strategies, we can further improve patient rapport with their physicians, resulting in positive patient outcomes.

Perceptions of Chaplains' Value and Impact Within Hospital Care Teams

Many scholars have written about the role of spirituality in health care. One mechanism for incorporating spirituality into the care of patients is to integrate clinically trained chaplains into hospital care teams. We examined in a mixed-methods fashion, the effects of this type of integrated care team within a teaching hospital setting. The quality and impact of chaplain involvement were studied from patient and physician-in-training perspectives, using data from more than 200 patients and physicians in training. Findings clearly show that clinically trained chaplains can contribute meaningful expertise and real value to the quality and comprehensiveness of patient and physician experiences.

Efficacy of Interventions to Reduce Resident Physician Burnout: A Systematic Review

BACKGROUND

Studies report high burnout prevalence among resident physicians, with little consensus on methods to effectively reduce it.

OBJECTIVE

This systematic literature review explores the efficacy of interventions in reducing resident burnout.

METHODS

PubMed, Embase, and Web of Science were searched using these key words: burnout and resident, intern, or residency. We excluded review articles, editorials, letters, and non-English-language articles. We abstracted data on study characteristics, population, interventions, and outcomes. When appropriate, data were pooled using random effects meta-analysis to account for between-study heterogeneity. Study quality was assessed using Newcastle-Ottawa Scale (cohort studies) and Jadad scale (randomized control trials [RCTs]).

RESULTS

Of 1294 retrieved articles, 19 (6 RCTs, 13 cohort studies) enrolling 2030 residents and examining 12 interventions met criteria, with 9 studying the 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) duty hour restrictions. Work hour reductions were associated with score decrease (mean difference, -2.73; 95% confidence interval (CI) -4.12 to -1.34; P < .001) and lower odds ratio (OR) for residents reporting emotional exhaustion (42%; OR = 0.58; 95% CI 0.43-0.77; P < .001); a small, significant decrease in depersonalization score (-1.73; 95% CI -3.00 to -0.46; P = .008); and no effect on mean personal accomplishment score (0.93; 95% CI -0.19-2.06; P = .10) or for residents with high levels of personal accomplishment (OR = 1.01; 95% CI 0.67-1.54; P = .95). Among interventions, self-care workshops showed decreases in depersonalization scores, and a meditation intervention reduced emotional exhaustion.

CONCLUSIONS

The ACGME work hour limits were associated with improvement in emotional exhaustion and burnout.

Effect of didactic lectures on obesity documentation and counseling among internal medicine residents

Background

Screening adult patients for obesity and offering appropriate counseling and treatment for weight loss is recommended. However, many healthcare providers feel ill-equipped to address this topic.

Objective

We examined whether didactic presentations lead to increased obesity documentation and counseling among internal medicine (IM) residents.

Methods

We reviewed medical records of patients seen at the IM Resident Continuity Clinic during April 2015. Residents were provided feedback at two didactic presentations during May 2015. To examine the effect of this intervention, we repeated medical record review during June 2015. For both reviews, we abstracted patient-specific (i.e., age, body mass index [BMI], race, sex, and number of comorbid diagnoses) and resident-specific (i.e., sex and training level) data as well as evidence of obesity documentation and counseling. We used logistic regression models to examine the effect of intervention on obesity documentation and counseling, adjusting for patient- and resident-specific variables.

Results

Of the 278 patients with BMI≥30 kg/m², 139 were seen before and 139 after the intervention. Intervention had no effect on obesity documentation or counseling with or without adjustment for confounding variables (both P>0.05). In adjusted post-hoc analyses, each additional comorbidity increased the odds of obesity documentation by 8% (OR=1.08; 95% CI=1.05–1.11; P<0.001). In addition, as compared to postgraduate year (PGY) 1 residents, PGY-3 residents were 56% (OR=0.44; 95% CI=0.21–0.95; P=0.03) less likely to counsel obese patients.

Conclusions

Obesity is inadequately addressed in primary care settings, and didactic presentations were unable to increase obesity documentation or weight loss counseling. Future research to identify effective interventions is needed.

Non-Volatile Flash Memory Characteristics of Tetralayer Nickel-Germanide Nanocrystals Embedded Structure

Formation of tetralayer memory structure having nickel-germanide nanocrystals using a Ge/Ni multilayers is proposed. X-ray diffraction study shows the NiGe (002) phase formation after proper annealing. Cross sectional HRTEM clearly shows the sharpness and the size (~4-6 nm) of the stacked nanocrystals embedded in the oxide matrix. A large anti-clockwise hysteresis memory win- dow of 13.4 Volt at ± 15 Volt is observed for the optimized samples. This large memory window indicates for the MLC applications. Frequency independent C-V curve confirms about the charge storage in the nanocrystals. A good charge retention and endurance characteristics are exhibited upto 125 °C for the nonvolatile memory application.

Who's in Our Neighborhood? Healthcare Disparities Experiential Education for Residents

BACKGROUND

Residents and fellows frequently care for patients from diverse populations but often have limited familiarity with the cultural preferences and social determinants that contribute to the health of their patients and communities. Faculty physicians at academic health centers are increasingly interested in incorporating the topics of cultural diversity and healthcare disparities into experiential education activities; however, examples have not been readily available. In this report, we describe a variety of experiential education models that were developed to improve resident and fellow physician understanding of cultural diversity and healthcare disparities.

METHODS

Experiential education, an educational philosophy that infuses direct experience with the learning environment and content, is an effective adult learning method. This report summarizes the experiences of multiple sponsors of Accreditation Council for Graduate Medical Education-accredited residency and fellowship programs that used experiential education to inform residents about cultural diversity and healthcare disparities. The 9 innovative experiential education activities described were selected to demonstrate a wide range of complexity, resource requirements, and community engagement and to stimulate further creativity and innovation in educational design.

RESULTS

Each of the 9 models is characterized by residents' active participation and varies in length from minutes to months. In general, the communities in which these models were deployed were urban centers with diverse populations. Various formats were used to introduce targeted learners to the populations and communities they serve. Measures of educational and clinical outcomes for these early innovations and pilot programs are not available.

CONCLUSION

The breadth of the types of activities described suggests that a wide latitude is available to organizations in creating experiential education programs that reflect their individual program and institutional needs and resources.

Bayesian analysis of two diagnostic methods for paediatric ringworm infections in a teaching hospital

Quantitatively, conventional methods of diagnosis of tinea capitis or paediatric ringworm, microscopic and culture tests were evaluated with Bayes rule. This analysis would help in quantifying the pervasive errors in each diagnostic method, particularly the microscopic method, as a long-term treatment would be involved to eradicate the infection by the use of a particular antifungal chemotherapy. Secondly, the analysis of clinical data would help in obtaining digitally the fallible standard of the microscopic test method, as the culture test method is taken as gold standard. Test results of 51 paediatric patients were of 4 categories: 21 samples were true positive (both tests positive), and 13 were true negative; the rest samples comprised both 14 false positive (microscopic test positivity with culture test negativity) and 3 false negative (microscopic test negativity with culture test positivity) samples. The prevalence of tinea infection was 47.01% in the population of 51 children. The microscopic test of a sample was efficient by 87.5%, in arriving at a positive result on diagnosis, when its culture test was positive; and, this test was efficient by 76.4%, in arriving at a negative result, when its culture test was negative. But, the post-test probability value of a sample with both microscopic and culture tests would be correct in distinguishing a sample from a sick or a healthy child with a chance of 71.5%. However, since the sensitivity of the analysis is 87.5%, the microscopic test positivity would be easier to detect in the presence of infection. In conclusion, it could be stated that Trychophyton rubrum was the most prevalent species; sensitivity and specificity of treating the infection, by antifungal therapy before ascertaining by the culture method remain as 0.8751 and 0.7642, respectively. A correct/coveted diagnostic method of fungal infection would be could be achieved by modern molecular methods (matrix-assisted laser desorption ionisation-time of flight mass spectrometry or fluorescence in situ hybridization or enzyme-linked immunosorbent assay [ELISA] or restriction fragment length polymorphism or DNA/RNA probes of known fungal taxa) in advanced laboratories.

Accounting for professionalism: an innovative point system to assess resident professionalism

BACKGROUND

Professionalism is a core competency for residency required by the Accreditation Council of Graduate Medical Education. We sought a means to objectively assess professionalism among internal medicine and transitional year residents.

INNOVATION

We established a point system to document unprofessional behaviors demonstrated by internal medicine and transitional year residents along with opportunities to redeem such negative points by deliberate positive professional acts. The intent of the policy is to assist residents in becoming aware of what constitutes unprofessional behavior and to provide opportunities for remediation by accruing positive points. A committee of core faculty and department leadership including the program director and clinic nurse manager determines professionalism points assigned. Negative points might be awarded for tardiness to mandatory or volunteered for events without a valid excuse, late evaluations or other paperwork required by the department, non-attendance at meetings prepaid by the department, and inappropriate use of personal days or leave. Examples of actions through which positive points can be gained to erase negative points include delivery of a mentored pre-conference talk, noon conference, medical student case/shelf review session, or a written reflection.

RESULTS

Between 2009 and 2012, 83 residents have trained in our program. Seventeen categorical internal medicine and two transitional year residents have been assigned points. A total of 55 negative points have been assigned and 19 points have been remediated. There appears to be a trend of fewer negative points and more positive points being assigned over each of the past three academic years.

CONCLUSION

Commitment to personal professional behavior is a lifelong process that residents must commit to during their training. A professionalism policy, which employs a point system, has been instituted in our programs and may be a novel tool to promote awareness and underscore the merits of the professionalism competency.

A multimethod approach for cross-cultural training in an internal medicine residency program

BACKGROUND

Cultural competence training in residency is important to improve learners' confidence in cross-cultural encounters. Recognition of cultural diversity and avoidance of cultural stereotypes are essential for health care providers.

METHODS

We developed a multimethod approach for cross-cultural training of Internal Medicine residents and evaluated participants' preparedness for cultural encounters. The multimethod approach included (1) a conference series, (2) a webinar with a national expert, (3) small group sessions, (4) a multicultural social gathering, (5) a Grand Rounds presentation on cross-cultural training, and (6) an interactive, online case-based program.

RESULTS

The program had 35 participants, 28 of whom responded to the survey. Of those, 16 were white (62%), and residents comprised 71% of respondents (n=25). Following training, 89% of participants were more comfortable obtaining a social history. However, prior to the course only 27% were comfortable caring for patients who distrust the US system and 35% could identify religious beliefs and customs which impact care. Most (71%) believed that the training would help them give better care for patients from different cultures, and 63% felt more comfortable negotiating a treatment plan following the course.

CONCLUSIONS

Multimethod training may improve learners' confidence and comfort with cross-cultural encounters, as well as lay the foundation for ongoing learning. Follow-up is needed to assess whether residents' perceived comfort will translate into improved patient outcomes.

Disclosure and documentation of reported unanticipated medical events or outcomes: need for healthcare provider education

In 2001 the Joint Commission on Accreditation of Healthcare Organizations added "requirement to disclose unanticipated outcomes" to accreditation standards. Full disclosure increases patient satisfaction and trust in physicians. Though studies suggest elements of complete disclosure, there are no national standards.

A young male with coexisting astrocytoma and renal cell carcinoma

Familial cancer syndrome is a genetic condition that causes an individual to be at increased risk for specific types of cancers. There are different familial cancer syndromes, each of which is associated with a specific set of characteristic cancers. Atypical presentations such as the combination of two types of cancers involving the same primary site with a slightly different pathology are not uncommon. The reason for such a high degree of phenotypic variation could be due to somatic mosaicisms which, although rare, have been reported in association with some of the familial cancer syndromes. We report a case of a 44-year-old Caucasian male with coexisting astrocytoma and Renal Cell Carcinoma (RCC), in whom the diagnosis of Von Hippel-Lindau (VHL) syndrome was considered. Although the patient tested negative for the classic VHL gene, the possibility of somatic mosaicism could not be ruled out. This case reflects the importance of having a high index of suspicion to screen the patients with more than one type of malignancies for familial cancer syndrome, as it may present with atypical features and the diagnosis of familial cancer syndrome has important implications in genetic counseling.

Know Your Audience

Purpose: To identify the chief complaints and demographics at Clinica Esperanza, a student-run free clinic for an underserved Hispanic population. Methods: A retrospective chart review of patient files from 2005 through 2010 was undertaken, as approved by the University of Tennessee Health Science Center’s Institutional Review Board. Results: From 2005 through 2010, Clinica Esperanza fielded 2551 patient visits, consisting of 951 unique patients, 609 females and 342 males. Mean age was 34 years, and 60% of patients presented once, while 13% followed up for 1 year, 9% for 2 years, 6% for 3, 6% for 4, and 4% for 5. “Pap smear,” “abdominal pain,” and “follow-up lab results” ranked, in order, as the 3 top chief complaints. Discussion: Resulting data have led to several improvements. The clinic has remained open weekly to improve patient continuity. With the top 10 chief complaints identified, they are better addressed. More funding is allocated for speculums and proper training of Pap smear technique. Systematic reporting of lab results is being implemented. Physical therapists and pharmacists now participate to address musculoskeletal and medication-based needs, respectively. A volunteer gastroenterologist has been recruited to provide specialized care for abdominal pain. An electrocardiogram machine is now used to evaluate chest pain. To improve student-patient communication, online language learning modules have been created. Conclusions: Based on these data, improvements in health care services have been made, including better continuity, emphasis on top chief complaints, and provider education in medical Spanish. Future plans include on-site pharmacy, smoother referrals, and similar clinics on the University of Tennessee Health Science Center’s other campuses.

Cold-induced urticaria with a familial transmission: a case report and review of the literature

Introduction

Cryopyrin-associated periodic syndrome is a rare genetic disorder causing cold-induced urticaria, severe arthralgias, and (potentially) renal failure and hearing loss. Therapies that effectively control the symptoms and prevent the complications of this debilitating disorder are now available, making recognition of this disease important.

Case presentation

A 60-year-old Caucasian woman presented with complaints of rash and joint pains to a general medicine clinic. Her history showed that her symptoms were linked to cold exposure, but the results of a cold stimulation time test were negative. Several generations of her family had similar symptoms.

Conclusions

This case highlights the importance of considering cryopyrin-associated periodic syndrome in the differential diagnosis of cold-induced urticaria. Several medications targeting interleukin-1-beta are available, providing significant relief from symptoms and improvement in quality of life in affected patients.

Transient binocular visual loss: a rare presentation of ventriculoperitoneal shunt malfunction

The authors report the case of a 27-year-old male with ventriculoperitoneal shunt (VPS) for hydrocephalus presenting with episodic transient binocular visual loss (TBVL) and headache. Complete physical, bedside shunt examination and funduscopy were unremarkable. Laboratory investigation, shunt series and imaging studies failed to reveal any acute abnormalities. Interrogation of the shunt system identified a valve malfunction which was corrected with resultant symptomatic relief and the patient was discharged home in stable condition. VPS malfunction occurs secondary to infection or mechanical failure such as obstruction, tubing fracture, shunt migration and over drainage. Resultant raised intracranial pressure leads to symptoms of headache, nausea, vomiting and gait abnormalities. Visual defects including blindness has been occasionally reported from shunt malfunction. Rare complications include cerebrospinal fluid oedema, colonic perforation, paraparesis and parkinsonism. TBVL due to shunt malfunction remains an uncommon presentation and requires a high index of clinical suspicion while evaluating these patients.

Enhancing teamwork between chief residents and residency program directors: description and outcomes of an experiential workshop

BACKGROUND

An effective working relationship between chief residents and residency program directors is critical to a residency program's success. Despite the importance of this relationship, few studies have explored the characteristics of an effective program director-chief resident partnership or how to facilitate collaboration between the 2 roles, which collectively are important to program quality and resident satisfaction. We describe the development and impact of a novel workshop that paired program directors with their incoming chief residents to facilitate improved partnerships.

METHODS

The Accreditation Council for Graduate Medical Education sponsored a full-day workshop for residency program directors and their incoming chief residents. Sessions focused on increased understanding of personality styles, using experiential learning, and open communication between chief residents and program directors, related to feedback and expectations of each other. Participants completed an anonymous survey immediately after the workshop and again 8 months later to assess its long-term impact.

RESULTS

Participants found the workshop to be a valuable experience, with comments revealing common themes. Program directors and chief residents expect each other to act as a role model for the residents, be approachable and available, and to be transparent and fair in their decision-making processes; both groups wanted feedback on performance and clear expectations from each other for roles and responsibilities; and both groups identified the need to be innovative and supportive of changes in the program. Respondents to the follow-up survey reported that workshop participation improved their relationships with their co-chiefs and program directors.

CONCLUSION

Participation in this experiential workshop improved the working relationships between chief residents and program directors. The themes that were identified can be used to foster communication between incoming chief residents and residency directors and to develop a curriculum for chief resident development.

Getting to the heart of rectal bleeding: subacute bacterial endocarditis presenting as anaemia and a GI bleed

In this case report, the authors demonstrate a case of subacute bacterial endocarditis presenting with anaemia. It is the first of its kind to describe a delay in diagnosis due to an initial patient investigation for a bleed rather than a cardiac evaluation. Astute clinicians need to be aware of the causes of anaemia in patients with endocarditis and consider that in Streptococcus bovis (S bovis) infection can be related to gastrointestinal polyps or malignancy resulting in bleeding. Although patients with S bovis endocarditis should undergo full gastrointestinal investigation after endocarditis is diagnosed, it should not delay medical treatment. In this article, the authors discuss the consequences of failing to achieve timely recognition of endocarditis along with common systemic complications. The authors also outline current recommendations for surgical intervention as heart valve replacement surgery was warranted in the patient to prevent fatal outcome.

Postinfectious glomerulonephritis: Is there a role for steroids?

The role of steroids in treatment of postinfectious glomerulonephritis (PIGN) has been controversial. The reason for such controversy is the risk of infection relapse associated with steroid therapy. Steroids may have a place in the treatment of resistant cases where renal function does not improve despite aggressive antibiotic therapy as well as in patients with crescentic form of PIGN. We report a case of a 39 year-old Caucasian man who was diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia resulting in acute IgA dominant PIGN that failed to respond to antibiotic treatment alone, but responded significantly to steroids in addition to antibiotics. This anecdotal experience suggests that steroids could be considered in conjunction with antibiotic therapy for the treatment of refractory cases of PIGN or crescentic form of PIGN. More studies with long-term follow-up of patients treated with steroids in addition to antimicrobial agents are required to quantify the risk of infection relapse with steroid therapy.

Removal of hexavalent chromium by biosorption process in rotating packed bed

Removal of hexavalent chromium ions from an aqueous solution by crude tamarind (Tamarindus indica) fruit shell was examined in a rotating packed bed contactor by continuously recirculating a given volume of solution through the bed. Reduction of Cr(VI) to Cr(III) within the biosorbent appeared to be the removal mechanism. Depletion rate of Cr(VI) from, and release of reduced Cr(III) ions into the aqueous phase, was influenced by mass transfer resistance besides pH and packing depth. A mathematical model considering the reduction reaction to be irreversible and incorporating intraparticle and external phase mass transfer resistances represented the experimental data adequately. The study indicated that the limitations of fixed bed contactor operating under terrestrial gravity in intensifying mass transfer rates for this system can be overcome with rotating packed bed due to liquid flow under centrifugal acceleration.

A rare cause of seizure masquerading as neoplasm

The authors report the case of a young man with no significant medical history who presented with new-onset seizure and mass-like lesions isolated to the left cerebral hemisphere relating to malignancy. Biopsy revealed findings consistent with angiitis and investigations for secondary causes of angiitis was negative. The diagnosis of primary angiitis of the central nervous system was made and the patient has responded well to treatment.

An "education for life" requirement to promote lifelong learning in an internal medicine residency program

BACKGROUND

Lifelong learning is an integral component of practice-based learning and improvement. Physicians need to be lifelong learners to provide timely, efficient, and state-of-the-art patient care in an environment where knowledge, technology, and social requirements are rapidly changing.

OBJECTIVES

To assess graduates' self-reported perception of the usefulness of a residency program requirement to submit a narrative report describing their planned educational modalities for their future continued medical learning ("Education for Life" requirement), and to compare the modalities residents intended to use with their reported educational activities.

MATERIALS AND METHODS

Data was compiled from the Education for Life reports submitted by internal medicine residents at the University of Tennessee College of Medicine Chattanooga from 1998 to 2000, and from a survey sent to the same 27 graduates 2 to 4 years later from 2000 to 2004.

RESULTS

Twenty-four surveys (89%) were returned. Of the responding graduates, 58% (14/24) found the Education for Life requirement useful for their future continued medical learning. Graduates intended to keep up with a mean of 3.4 educational modalities, and they reported keeping up with 4.2. In a multivariable analysis, the number of modalities graduates used was significantly associated with the number they had planned to use before graduation (P  =  .04) but not with their career choice of subspecialization.

CONCLUSION

The majority of residents found the Education for Life requirement useful for their future continued medical learning. Graduates, regardless of specialty, reported using more modalities for continuing their medical education than they thought they would as residents. Considering lifelong learning early in training and then requiring residents to identify ways to practice lifelong learning as a requirement for graduation may be dispositive.

Primary pulmonary choriocarcinoma in a male

The authors report a case of a 48-year-old male smoker who presented with respiratory distress and constitutional symptoms along with gynaecomastia and multiple pulmonary nodules. Based on normal physical and ultrasound findings of the testes, presence of markedly elevated serum β human chorionic gonadotrophin (HCG) and biopsy findings of the lung a diagnosis of primary pulmonary choriocarcinoma was made.

Beer potomania: a case report

A syndrome of hyponatraemia associated with excessive beer drinking was first recognised in 1971. This syndrome has been referred to as beer potomania. Dilutional hyponatraemia occurs due to excessive consumption of an exclusive beer diet which is poor in salt and protein. We report a case of beer potomania who improved dramatically with introduction of solute load, with no subsequent neurological sequelae.

Do women residents delay childbearing due to perceived career threats?

PURPOSE

To assess gender differences among residents regarding their plans to have children during residency and determine the most influential reasons for these differences.

METHOD

Using the Health Belief Model as a framework, the authors created an instrument to survey 424 residents from 11 residency programs at three academic medical institutions about their intentions to have children during residency. The authors developed a scale to assess the perceived career threats of having children during residency, evaluated its psychometric properties, and calculated the effect of the mediators.

RESULTS

The response rate was 77% (328/424). Forty-one percent of men versus 27% of women planned to have children during residency (P = .01). The instrument measured four career threats-extended training, loss of fellowship positions, pregnancy complications, and interference with career plans-on a five-point Likert scale. The scale had a Cronbach alpha of 0.84 and an eigenvalue of 2.2. Compared with men, women had higher scores for each item and a higher mean score (2.9 versus 2.1, P = .001), signifying greater belief in the potential of pregnancy to threaten careers. After adjusting for age, institution, postgraduate year, and knowledge of parental leave policies, women were less likely to plan to have children during residency (odds ratio 0.46 [95% confidence interval 0.25-0.84]). In mediation analysis, threats to career explained 67% of the gender variance.

CONCLUSIONS

Women residents intentionally postpone pregnancy because of perceived threats to their careers. Medical educators should be aware of these findings when counseling female trainees.

Dural based mass: malignant or benign

In March 2007, a 68 year old female was diagnosed with colonic adenocarcinoma metastatic to the lungs and a frontoparietal parafalcine lesion suspected to be a meningioma was also noted. She denied neurologic symptoms and resection of the parafalcine lesion did not occur. For 14 months, she received chemotherapy with poor response. In June 2008, she developed multiple focal neurologic deficits. Enlargement of the parafalcine brain lesion was noted on head computerized tomography and magnetic resonance imaging. Cerebral angiogram demonstrated a parafalcine mass supplied by the middle meningeal artery. All 3 modality findings confirmed a meningioma. Embolization of the middle meningeal artery with craniotomy for excision of the suspected meningioma was performed. Pathology indicated metastatic adenocarcinoma with colonic primary without evidence of meningioma. Meningiomas are the most common dural based lesions; however, a variety of dural lesions mimic meningiomas. Dural metastatic tumors mimicking meningiomas is an uncommon phenomenon, particularly when the primary location is the colon. This paper additionally discusses the differentiation of benign dural based tumors like meningiomas from malignant findings. Multiple adjunct studies can differentiate meningiomas from metastatic tumor. The definitive diagnosis is based on histopathology.

Increased frequency and nocturia in a middle aged male may not always be due to Benign Prostatic Hypertrophy (BPH): a case report

Primary signet ring cell carcinoma of urinary bladder is a rare type of bladder tumor and carries a very high mortality rate. It may have a clinical presentation similar to common diseases like Benign Prostatic Hypertrophy (BPH) and the management options are extremely limited. We report a case of 58 year old Caucasian male who presented with a 5 month history of increased frequency of urination, nocturia and weight loss without any fever or hematuria. He was found to have an increased creatinine of 2.8 mg/dl and a prostate specific antigen level of 0.18 ng/ml. His azotemia was thought to be secondary to BPH. A foley catheter was initially placed with a plan for outpatient follow up. On removal of the catheter his problems persisted and he returned to the hospital. Diagnostic work up including abdominal ultrasonography, computed tomography (CT) scan, retrograde pyelogram, cystography and cystoscopic biopsies revealed the diagnosis of primary signet ring cell carcinoma of urinary bladder. Although cystectomy was planned, our patient passed away before this could be done.

[Relapse after surgical treatment of mycobacterium ulcerans infection (buruli ulcer): study of risk factors in 84 patients in the Democratic Republic of the Congo]

OBJECTIVE

To identify risk factors for relapse after exclusively surgical treatment of Mycobacterium ulcerans infection (Buruli ulcer).

METHODS

Study was carried out in 102 patients treated exclusively by surgery for Buruli ulcer at various care facilities in the Congo from January 1, 2000 to January 1, 2005.

RESULTS

Outcomes included relapse in 22 patients (21.5%), cure in 62 (60.7%), and unknown in 18 (17.6%). Statistical analysis identified the following variables as independent risk factors for relapse after exclusively surgical treatment: incomplete surgical excision (OR = 91.83; P = 0.0000; IC to 95%), age under 16 years (OR = 14.80; P = 0.0000; IC to 95%) and pre-ulcerative Buruli lesions (edema and plaque) (OR = 3.18; P = 0.0215; IC to 95%).

CONCLUSION

Quality of excision, patient age, and clinical form of lesion are the main predictors of relapse after isolated surgical treatment of Buruli ulcer.

Milk-alkali syndrome in a middle-aged woman after ingesting large doses of calcium carbonate: a case report

INTRODUCTION

Most cases of hypercalcaemia are secondary to malignancy or primary hyperparathyroidism. Here we report a case of hypercalcaemia that we have attributed to milk-alkali syndrome.

CASE PRESENTATION

A 51-year-old Caucasian woman with a past history of thyroidectomy and parathyroidectomy secondary to thyroid cancer developed an altered mental state and had an extremely high calcium concentration of 22.8 mg/dl (5.7 mmol/l). Investigations included work up for malignancy and hyperparathyroidism. However, the hypercalcaemia was attributed to ingestion of large doses of calcium carbonate, leading to milk-alkali syndrome. She was managed with intravenous fluids and withdrawal of calcium carbonate. The patient responded well to treatment, with normalization of the calcium concentration and clinical improvement.

CONCLUSION

We present this case to remind clinicians of the importance of detailed history taking and of milk-alkali syndrome as a cause of hypercalcemia.

Increased frequency and nocturia in a middle aged male may not always be due to benign prostatic hypertrophy: a case report

Primary signet ring cell carcinoma of urinary bladder is a rare type of bladder tumor and carries a very high mortality rate. It may have a clinical presentation similar to common diseases like benign prostatic hypertrophy and the management options are extremely limited. We report a case of 58-year-old Caucasian male who presented with a 5 month history of increased frequency of urination, nocturia and weight loss without any fever or hematuria. He was found to have an increased creatinine of 2.8 mg/dl and a prostate specific antigen level of 0.18 ng/ml. His azotemia was thought to be secondary to BPH. A Foley catheter was initially placed with a plan for outpatient follow up. On removal of the catheter his problems persisted and he returned to the hospital. Diagnostic work up including abdominal ultrasonography, computed tomography scan, retrograde pyelogram, cystography and cystoscopic biopsies revealed the diagnosis of primary signet ring cell carcinoma of urinary bladder. Although cystectomy was planned, our patient passed away before this could be done.

Achieving the AAAs of Ambulatory Care: Aptitude, Appeal, and Appreciation

BACKGROUND

In the current health care environment more patient care has moved from in-hospital care to the ambulatory primary care settings; however, fewer internal medicine residents are pursuing primary care careers. Barriers to residents developing a sense of competency and enjoyment in ambulatory medicine include the complexity of practice-based systems, patients with multiple chronic diseases, and the limited time that residents spend in the outpatient setting.

OBJECTIVE

In an effort to accelerate residents' ambulatory care competence and enhance their satisfaction with ambulatory practice, we sought to change the learning environment. Interns were provided a series of intensive, focused, ambulatory training sessions prior to beginning their own continuity clinic sessions. The sessions were designed to enable them to work confidently and effectively in their continuity clinic from the beginning of the internship year, and it was hoped this would have a positive impact on their perception of the desirability of ambulatory practice.

METHODS

Improvement needs assessment after a performance, so we developed a structured, competency-based, multidisciplinary curriculum for initiation into ambulatory practice. The curriculum focused on systems-based practice, patient safety, quality improvement, and collaborative work while emphasizing the importance of continuity of care and long-term doctor-patient relationships. Direct observation of patient encounters was done by an attending physician to evaluate communication and physical examination skills. Systems of care commonly used in the clinic were demonstrated. Resources for practice-based learning were used.

CONCLUSION

The immersion of interns in an intensive, hands-on experience using a structured ambulatory care orientation curriculum early in training may prepare the intern to be a successful provider and learner in the primary care ambulatory setting.

Band of cacophony - abdominal catastrophe caused by the fibrous band of Meckel's diverticulum: a case report

Introduction

This report calls attention to small bowel necrosis resulting as a complication of formation of an obstructive loop of small bowel around a band of Meckel's diverticulum.

Case presentation

We report a case of an adult in his 5th decade presenting with sharp, colicky abdominal pain. On presentation his vitals were within normal limits, abdomen was non-distended but tender and rigid all over, more on left lower quadrant without any rebound tenderness. Bowel sounds were hypoactive. Rectal exam showed an empty vault. White blood cell count was 9.0 x 103/mm3 with 94.5% neutrophils, Hb of 9.0 gm/dl and Hct of 31.3%, liver and pancreatic enzymes were not elevated. Arterial blood gas did not show any acidosis and lactic acid level was not elevated. X-ray showed a non-obstructive bowel pattern without any free air. Abdominal computed tomography with oral and intravenous gastrograffin showed findings consistent with complete mid to distal small bowel obstruction secondary to a closed loop obstruction. Emergent laparotomy showed a Meckel's diverticulum that had formed a band around a portion of small bowel causing it to twist upon itself and become necrotic.

Conclusion

Histopathology revealed Meckel's diverticulum and benign intestinal tissue with hemorrhagic necrosis.

A sore throat--potentially life-threatening?

A sore throat, which is most commonly viewed as a minor ailment, can be a manifestation of a life-threatening disorder known as Lemierre's syndrome caused by Fusobacterium necrophorum. We report a new case of Lemierre's syndrome that occurred in an otherwise healthy 18-year-old woman, who initially presented with fever and sore throat. The diagnosis was not made until a week later when blood cultures became available. This syndrome should be suspected until proven otherwise in any patient with signs of pharyngitis, a painful swollen neck, and pulmonary symptoms. By presenting this curable, but potentially life-threatening case of Lemierre's syndrome, we hope to increase the awareness of the early clinical manifestations of Lemierre's syndrome and to emphasize the importance of careful physical examination with special attention to the neck. Clinicians should be aware that exclusion of streptococcal infection in a patient with severe tonsillar infection does not exclude a bacterial cause.

Locked lung by looped hernia: a case report

Background

Large pleural effusions are usually symptomatic. We report a patient with asymptomatic massive left sided pleural effusion with left lung collapse secondary to a traumatic diaphragmatic hernia.

Case presentation

A 44 year old male presented with recurrent pleural effusions over six weeks. His pleural effusion was first diagnosed incidentally on a chest X-ray after a fall. Extensive diagnostic studies were unyielding for the etiology of the effusion. A diagnostic and therapeutic video assisted thoracoscopy revealed a diaphragmatic hernia with inflamed, incarcerated omentum. After hernia repair there was no recurrence.

Conclusion

This case underscores the obscure presentation of an incarcerated diaphragmatic hernia presenting as massive recurrent pleural effusions.

Limited Wegener's granulomatosis presenting as lung nodules in a patient with rheumatoid arthritis: a case report

Background

Rheumatoid arthritis has varied pleuroparenchymal manifestations. Wegener's granulomatosis can develop in an established case of rheumatoid arthritis and this association although previously reported is very rare.

Case presentation

A 60-year-old lady had been diagnosed with rheumatoid arthritis on the basis of her clinical symptoms and serological tests which were positive RA factor and anti-CCP antibodies. Her rheumatoid arthritis activity had been mild and well controlled with hydroxychloroquine and low dose prednisone. She presented with a productive cough and right-sided pleuritic chest pain. CT scan of the chest showed three lung nodules with increased uptake on PET CT scan, raising concerns for an inflammatory or malignant process. The differential diagnosis included rheumatoid nodules, infections or malignancy. A CT-guided needle biopsy of the largest nodule was undertaken which showed vasculitis typical of Wegener's granulomatosis. Stains and cultures of the biopsy specimen were negative for bacteria, fungi and acid fast bacilli. A panel of serological tests for vasculitis were checked and showed elevated titers of cANCA and anti-proteinase 3 antibodies. Urine analysis and CT scan of paranasal sinuses was normal. Since the upper respiratory tract and the kidneys were spared a diagnosis of limited Wegener's granulomatosis affecting only the lungs was made. Due to the toxicity of cyclophosphamide, her relatively mild disease sparing the kidneys and the underlying rheumatoid arthritis, weekly methotrexate was started and low dose prednisone was continued. She had marked symptomatic improvement and complete resolution of the nodules was documented on subsequent imaging.

Conclusion

Wegener's granulomatosis developing in a patient with rheumatoid arthritis is very rare but should be considered as it warrants a different and possibly more aggressive treatment approach.